2016 is a Presidential election year and it is rarely to either party's advantage to be engaged in a prolonged legislative session, rather than being "freed up" to be back home mingling with voters. One would expect the Department of Defense (DoD) appropriations and authorization bills will be quickly "marked-up" and incorporated in a short-term Continuing Resolution (i.e., funding made available for FY'17) until after the election, with the Congress then returning to complete their deliberations quickly – the ultimate decisions depending upon how the nation voted. The recent Committee "requests" for personal Member recommendations is consistent with this scenario. Working on the Hill provides one with an appreciation for the gradual "waves of change" which can result in substantive modifications in the status quo. One can almost feel when this "ebb and flow" occurs.
A Changing Dialogue: One of Senator Inouye's first amendments to the DoD CHAMPUS program, back in the late 1970's, was to allow beneficiaries direct access to the services of certified nurse midwives. When he offered that amendment he had also included a provision to recognize psychiatric mental health nurse practitioners. His colleagues were very hesitant to support the latter; however, they enthusiastically endorsed the nurse midwifery provision with several senior members commenting that they themselves had been delivered by a nurse midwife.
Times have changed, especially surrounding our nation's dialogue on mental/behavioral health. When President Obama addressed the adverse consequences of solitary confinement, he was alluding to introductory psychology. Mental health courts, including those for Veterans, are increasing in number. Earlier this year, the U.S. Preventive Services Task Force recommended for the first time that women be screened during pregnancy and after childbirth for depression as part of their normal health-care routine. Neil Kirschner, a former APA Congressional Science Fellow, facilitated the American College of Physicians (ACP) support for the integration of behavioral health care into primary care and having all health care professionals consider the behavioral and physical health of their patient if they are to be treated as a "whole person." Leading the way was U.S. Army Surgeon General Patty Horoho's vision of the healthcare "Lifespace" where individuals and their families make the choices that really impact their lives and health, and her personal collaboration with Barbara Van Dahlen of Give an Hour.
During deliberations on the FY'16 DoD Appropriations bill, the U.S. Senate included several provisions which are directly relevant to military psychologists and behavioral health providers. This in itself is most impressive. "The Committee recognizes that servicemembers and their families face unique stresses beyond those of everyday life. After over a decade of war, the need for mental health professionals in the Department is at an all-time high, and the Committee believes that every beneficiary of the Military Health System should have timely access to mental health services. However, the Committee is concerned with the Department's inability to recruit and retain enough psychiatrists, psychologists, social workers, nurse practitioners and registered nurses to provide adequate mental healthcare…. (T)he Assistant Secretary of Defense (Health Affairs) is directed to prepare… a review of these estimates as well as an outline of current challenges in recruiting and retaining mental health professionals by the Department of Defense."
The Uniformed Services University of the Health Sciences (USUHS): USUHS's mission is to be responsive to the unique needs of DoD and the USPHS; the four Surgeon Generals serving on its Board of Regents. There have been increasing collaborative efforts between the leadership of the department of psychology and psychiatric nursing, focusing upon interprofessional models of care and training, which are a high priority for the University's President. For example, they jointly utilize the simulation center with its standardized patients (i.e., skilled actors) and have participated together in the signature training event "Operation Bushmaster."
Recently, David Riggs, newly appointed psychology chair, and his nursing counterpart, Jess Calohan, have begun exploring ways to expand these earlier efforts; perhaps by having targeted modules integrated into their respective curricula. It would be relatively straightforward to re-start the psychopharmacology training program given that USUHS nurses are already trained to provide that clinical service. Of interest, the Senate Appropriations Committee had noted: "Prescription Effectiveness of Psychotropic Medications. – The Committee supports the Department's efforts to treat patients diagnosed with behavioral health disorders and believes that the ongoing efforts to use database-supported methods in order to increase the accuracy and effectiveness of prescription practices for mental health medications may not only achieve cost savings but also improve patient care. The Committee encourages the expansion of this research to additional sites as preliminary findings have shown promising results."
We would rhetorically ask: Does psychology want to be involved and remain relevant? At one point, we asked: Where in this discussion were those psychologists who were themselves Veterans? William Danton, a veteran and former Associate Chief of Staff for Mental Health in the VA, responded that he is vehemently opposed to RxP for psychologists precisely because he values quality of care! During our subsequent discussion: "Of course I value my colleagues and I'm sure they could do as well or better than our psychiatry brethren. It is the plethora of dangerous and often ineffective psychiatric medications I object to. It is the clear and inappropriate influence of pharma that will indiscriminately poison practitioners of all professions. If only psychologists were immune to that. However, as we have seen from the DoD debacle, money often drives practice." Reasonable professionals can clearly differ.
Watching the Shifting Currents: Last year the DoD Appropriations conferees included language that may be prophetic. "Concerns remain regarding the transfer of funds from the In-House Care budget sub-activity to pay for contractor-provided medical care. To limit such transfers and improve oversight within the Defense Health Program operation and maintenance account, the agreement includes a provision which caps the funds available for Private Sector Care under the TRICARE program subject to prior approval reprogramming procedures." On August 21, 1959 Hawaii achieved Statehood. Citizens living on the neighboring islands who required inpatient care relied upon the State to provide these services, as one of its most basic responsibilities. On January 14, 2016 Hawaii's Governor signed a transfer agreement allowing Kaiser Permanente to assume control of the three financially-struggling public hospitals on Maui. This action is estimated to save the State $260 million over 10 years. Whether in the long run this is a good policy or not, rests upon one's fundamental belief in the role of government. We would proffer that a similar debate exists regarding the delivery of health care to our nation's active duty personnel, their families, and our Veterans. "I feel so broke up, I wanna go home." Aloha,
Pat DeLeon, former APA President – Division 19 – February, 2016
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